GLOBAL HEALTH: DYNAMIC ROLES FOR THE APRN/APN

Kathy J. Wheeler, Lorna L. Schumann,

Gene Harkless, Catherine G. Ling, Beverly Bird,

and Patricia Maybee

6

GLOBAL HEALTH: DYNAMIC ROLES FOR THE APRN/APN

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.

--Margaret Mead

Advanced practice nursing is on a rapidly unfolding evolutionary path globally, dictated by need, vision, and opportunity. The need for cost-effective quality health care providers is universal. Technology and communications have allowed global connections, thus effectively making the world small. Educational systems and methods have concurrently evolved. Individuals and organizations involved in health care delivery have seen and learned from each other at a pace not seen before. Patients, people, and providers have continued and, in some instances, accelerated transitory movements, relocating regionally and internationally. These factors have resulted in several occurrences regarding the role of the advanced practice registered nurse (APRN): (a) the advanced practice role is emerging and evolving in many countries; (b) those in the advanced practice role need to understand the global community in order to serve, educate, and treat that community; and (c) the migration of people has created global communities that can be served by APRNs.

GLOBAL APRN ROLES AND TRENDS

One of the most confusing aspects of advanced practice nursing pertains to the titling, definitions, and interpretations of the various APRN roles throughout the world. Only recently has the United States settled on consistent terms and definitions through the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). The APRN Advisory Committee, through the consensus model, settled on the global term advanced practice registered nurse (APRN). The consensus model further delineated four roles: certified

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registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). APRNs in the United States are to be educated in one of these four roles but must also be educated in one or more of six population foci: the family/ individual across the life span; adult-gerontology; pediatrics; neonatology; women's health/gender related; or psychiatric/mental health. The consensus model is broader than merely setting titles--its underlying purpose was to create a document that "defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation" (p. 4). The model is still in the process of implementation in U.S. states and territories.

Just as the United States has struggled over titles, terms, and role interpretations, the same can be said of advanced practice nursing outside the United States. Many countries have chosen to recognize and encourage expanded roles for nurses beyond that of registered nurse, having done so uniquely and with great variety. The International Council of Nurses (ICN) reports that 70 countries have or are developing advanced practice roles for nurses. In 2002 the ICN defined an APN as a registered nurse who has acquired the expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which he or she is credentialed to practice. A master's degree is recommended for entry level. This term, advanced practice nurse (APN), is the commonly accepted international term. Despite the definition, defining characteristics, competencies, and scopes of practice, there is tremendous variation in titles, education, credentialing, policies, recognition, and support worldwide. A 2008 Web-based survey identified 13 different titles for APNs in countries recognizing advanced practice. The same survey also showed the following in respondent countries: 71% had some sort of APN education, 50% cited the master's degree as the primary credential, 72% had formal recognition of the role, and 48% had licensure or renewal requirements (Pulcini, Jelic, Gul, & Loke, 2009). Although showing tremendous advancement of the role, these data establish a clear need for some uniformity of role underpinnings.

A meeting was convened in 2014 to discuss APN practice around the globe as the importance for improved access to cost-effective, quality care in parts of the world where the APN role is absent or underutilized was recognized. The meeting brought together 30 health leaders from around the world. Attendees included representatives from the ICN, multiple universities, multiple ministries of health, the Organization for Economic Co-operation and Development (OECD), the Commission on Graduates of Foreign Nursing Schools (CGFNS), and other health organizations. The first recommendation of the report focused on removing the barriers to practice for APNs. These barriers are identified by the Global APN Nursing Symposium as follows:

? Lack of defined role for APNs ? Inconsistent educational and training standards

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? Inconsistent or unnecessary regulation ? Unstable health care funding from government or third-party payers

Key findings were summarized as follows:

? APNs have the potential to play a much larger role in improving the health of people worldwide.

? Different nations are in different stages of developing their nursing workforce, and opportunities for advanced nursing practice vary significantly from country to country.

? Countries where APNs have a well-defined role and greater practice authority have increasingly used nurses to improve access to primary and preventive health care.

? APNs have been successfully deployed in both developed and developing countries to improve health.

? APNs around the globe have worked with governments, consumer groups, funders, investors, and business leaders to create innovative programs and interventions that improve people's health.

? APNs can be a cost-effective solution to existing health care access and quality problems, but additional data are needed to fully evaluate and capture the value of their services.

Based on these issues, the group recommended the following:

? Standardize the definition of the APN role. ? Improve the educational curricula for APNs while respecting each coun-

try's unique cultural and political context. ? Increase access to primary and preventive health care services by remov-

ing policy barriers that prevent APNs from practicing to the full extent of their education and training. ? Reform health care funding mechanisms to allow for APN-based practice models. ? Collect data and share information on APN quality and outcomes in a variety of countries/settings.

The full results of this meeting are detailed in the 2014 Global Advanced Practice Nursing Symposium--The Future of Nursing Across the Globe document (Hansen-Turton, 2014).

Although the role will evolve according to unique regional issues, there are commonalities, such as the universal need for cost-effective quality care, APRNs can meet the need, and support for APRNs is through the development and maintenance of polices that provide the education, practice, and research frameworks.

BROADER GLOBAL TRENDS AND NEEDS

To prepare for a global experience, the APRN should understand the political, social, economic, and health care trends. Bass (2011) provided a comprehensive listing of megatrends to consider, detailed in Table 6.1. Megatrends

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TABLE 6.1 Megatrends Health

Education

Government and Society

? Longer life* ? Healthier life* ? Chronic is normal

Demographics

? Better educated* ? Distance education the

norm

Food and Agriculture

? Flattening world ? Pockets of instability

Environment

? Older consumer Economy

? Stable currently but linked ? Business measure

to environment

? Need to know

Transportation

Energy

? Water as currency Science and Technology

? Security challenged ? Infrastructure affected ? Tight economics

Work

? Oil important, not king Business

? Bandwidth is distance ? Context is king

Security

? Automation of normal ? Skills gap and need for

reskilling ? Technology-enhanced

employees

Religion

? New competitors ? Competition everywhere

Law

? Hacking is free

? Expanding impact

? Relative stability

*Not all the world may participate. Source: Bass (2011, p. 1).

are defined as high-level trends that generally operate broadly, outside of industry and geography. Of interest to APRNs are the predictions of longer, healthier lives; disease as the norm; water as an economic factor; and distance education as the future. On this last issue, APRNs have been leaders, educating providers while maintaining quality outcomes. This has happened within regions and nations--can the process be duplicated globally?

Recently, the global health care megatrends have been elaborated. These megatrends are technological advances, personalized medicine, the demand for evidence-based medicine, increased influence by payers, over treatment decisions in emerging economies, aging populations, rising costs, global pandemics, environmental challenges that overwhelm the current system, nonphysician providers, the growing role of philanthropy, prevention, and medical tourism becoming the next big business opportunity (Dillon & Prokesch, 2014).

To celebrate its 100th anniversary the ICN (2002b) released the Guidebook for Nurse Futurists in 2002, listing societal, health, and nursing trends, detailed in Table 6.2. Although developed in 2002, the list is still valid today.

One trend that should be examined further is "population growth." The United Nations (2013) estimates the world's population will reach 9.6 billion by 2050. The prediction suggests populations in developed regions

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TABLE 6.2 International Council of Nurses (ICN): Trends Affecting the Future of Nursing

TRENDS IN THE LARGER SOCIETY

HEALTH TRENDS

NURSING TRENDS

Information Technology

Economic-Driven Health Care Reform

Nursing Education Changes

? Rapid advances occur in information technology.

? Communication worldwide is improved via international networks and advanced language translation.

? Problems of information security and privacy need to be considered.

? Financial pressures exist ? Budget-constrained

to limit the costs of health governments are less

care.

committed to supporting

? Health care is being

nursing education.

restructured, with nurses ? Inflexible nursing pro-

increasingly being

grams are out of touch

recognized as full partners with service needs and

in cost-effective health care increasingly irrelevant to

delivery.

nursing practice.

? Economics conflicts with ? Visionary and experienced

the needs of patients.

nurses go into schools to

teach and serve as mentors.

? Nurses receive higher and

broader education.

Social Change/Unrest

Use of Technology in Caring Advances in Nursing

? Cooperation and embracing ? More money goes to high ? Nurses are leading the

of diversity is what society tech.

health promotion effort

increasingly expects of

? High-tech drives our high

throughout the world.

itself.

touch.

? Nurses become the entry

? Political and social unrest, ? Nurses humanize the use

point into the health care

stresses from rapid change of technology and never

system.

increase.

forget the importance of ? Internet-enabled technology

? Fundamentalism, split

personal caring and touch. helps nurses establish

between rich and poor,

a strong research base

terrorism increase.

for improving clinical

practice.

Globalization

Research and Development Turmoil in the Nursing of New Therapies/Techniques Profession

? Globalization of commerce ? Causes of cancer and

and exchanges of infor-

AIDS are discovered.

mation create greater

? Research focuses

prosperity and mutual

increasingly on problems

understanding.

of the poor, such as

? There is less of a nation-

malnutrition, malaria,

state orientation, more

and water contamination.

sense of global identity.

? Economic problems

are contagious in an

interconnected global

economy.

? There is a shortage of nurses at the bedside with downsizing of the nursing profession.

? Untrained personnel work as nurses worldwide.

? International nursing organization specialization increases.

(continued)

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